Killer Nathaniel John could have been prevented, says report
The death of a man who was killed by a fellow hostel resident suffering from schizophrenia could have been prevented, a review has found.
Nathaniel John slashed Stephen Rees's throat at a hostel in Roath run by Cardiff Mind in March 2011.
A report by Healthcare Inspectorate Wales (HIW) highlighted missed opportunities to engage John with mental health services.
HIW said it was vital the risk of such incidents was minimised.
John, who was then 27, attacked Mr Rees, 53, at the hostel where they were both living before phoning and ambulance, but he later died of his injuries.
John admitted manslaughter on the grounds of diminished responsibility at Cardiff Crown Court in December 2011, and was remanded to a secure hospital indefinitely.
A report following a review of the killing said it was clear the attack would not have happened if the two "very vulnerable" men had not been housed together.
But it said despite the risk of violence that John posed, the fact he would go on to commit an "act of murder" could not have been predicted.
Had John's schizophrenia been diagnosed earlier and he had complied with any subsequent treatment, the killing of Mr Rees "was preventable", the report said.
The review found both men had severe alcohol problems and made regular trips to the local pub.
Mr Rees was very well-known to psychiatric services and received a high level of support, but John was undiagnosed and had no meaningful contact with mental health services, the report said.
A number of failings were identified including:
- opportunities were missed by mental health services to diagnose John's mental illness
- weaknesses in communication and information sharing between services and agencies that had contact with John
- information that could have influenced John's care and treatment was missed
- weaknesses in the risk assessment of housing both Mr Rees and John
The report made six recommendations to Cardiff and Vale University Health Board, including reviewing its mental health referral process and the arrangements for providing psychiatric services for homeless people.
HIW chief executive, Kate Chamberlain, said: "Incidents of this type of extremely rare and the purpose of our investigation was to identify learning, to ensure that mental health services are better able to minimise the risk of similar incidents in the future."
Chief Medical Officer for Wales, Dr Ruth Hussey, said it was vital everything possible was done to identify shortcomings and put in place measures to reduce the risk of such incidents happening again.
Adam Cairns, chief executive at Cardiff and Vale University Health Board, said: "We thank HIW for their report and we commit to working with our local government colleagues and MIND Cymru with whom we will be addressing the issues raised."